Question

The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

Answer 1

Correct Answers:

The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.

Rationale :

Strenuous activity after cataract surgery increases intraocular pressure, risking complications such as hemorrhage or lens displacement. Clients should avoid heavy lifting, bending, or vigorous exercise for several weeks.

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Answer 2

Correct Answers:

A patient with a new-onset of confusion and restlessness.

Rationale :

Sudden confusion and restlessness suggest hypoxia, stroke, or worsening cardiac function. This change in mental status is a critical finding requiring immediate assessment. Delayed intervention may result in severe neurological or systemic complications.

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Answer 3

Correct Answers:

Hyperkalemia.

Rationale :

In the oliguric phase of acute kidney injury (AKI), the kidneys cannot excrete potassium, leading to hyperkalemia. This electrolyte imbalance can cause cardiac arrhythmias and requires immediate treatment. Monitoring and managing potassium levels is crucial in AKI.

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Answer 4

Correct Answers:

Beta blockers
Athletics
Sleeping

Rationale :

Sinus bradycardia may be caused by beta-blockers, athletic conditioning (increased vagal tone), and sleeping. Identifying the underlying cause guides appropriate management.

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Answer 5

Correct Answers:

Accommodation.

Rationale :

Accommodation is the ability of the eye to adjust focus between near and distant objects. Pupil constriction for near vision and dilation for distant vision is a normal finding. This response is controlled by the autonomic nervous system.

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Answer 6

Correct Answers:

Atropine

Rationale :

Atropine is the first-line treatment for symptomatic bradycardia as it increases heart rate by blocking parasympathetic stimulation. If ineffective, other interventions like pacing or epinephrine may be necessary. Prompt administration prevents further hemodynamic compromise.

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Answer 7

Correct Answers:

Have you had a recent infection?

Rationale :

Guillain-Barré syndrome (GBS) is often preceded by viral or bacterial infections, such as Campylobacter jejuni or respiratory infections. The immune response mistakenly attacks peripheral nerves, causing weakness and paralysis. Identifying a recent infection supports the diagnosis.

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Answer 8

Correct Answers:

Pulmonary edema.

Rationale :

In AKI, fluid overload occurs due to reduced kidney function, leading to pulmonary edema. Symptoms include dyspnea, crackles, and decreased oxygen saturation. Managing fluid balance is critical in preventing respiratory distress.

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Answer 9

Correct Answers:

Sudden pain relief.

Rationale :

A ruptured tympanic membrane in otitis media with effusion releases pressure, leading to sudden pain relief. However, it increases the risk of infection and hearing loss. Prompt medical evaluation is necessary for management.

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Answer 10

Correct Answers:

Avoid smoking.
Call 911 if your peak flow meter reading is in the red zone.
Wash bedclothes in hot water.
Ensure to use your inhaler at least 30 minutes before exercising.

Rationale :

Smoking, allergens, and dust mites trigger asthma attacks. Washing bedclothes in hot water helps reduce allergens. Using a rescue inhaler before exercise preempts exercise-induced bronchospasm by opening airways. Proper trigger management prevents exacerbations.

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QLexNursing

1 : The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

2 : The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

3 : A nurse in the med-surgical ICU is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

4 : There are several factors that may cause a patient to present with sinus bradycardia. What are some causes of sinus bradycardia? (Select all that apply.)

5 : The nurse is assessing a client's eyes and notes that when the client looks at a near object, the pupil constricts, but when the client looks at an object in the distance, the pupil dilates. The nurse should identify this finding as which condition?

6 : A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

7 : A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

8 : The nurse is caring for a client who is in the oliguric phase of an acute kidney injury. Which of the following clinical manifestations would be consistent with the condition?

9 : A nurse is caring for a child who has otitis media with effusion. The nurse should identify which of the following manifestations indicates a tympanic membrane rupture?

10 : The nurse is teaching a client with newly diagnosed asthma. Which instructions should the nurse include to reduce the likelihood of an asthma attack? (Select all that apply.)